CurrentUnitedHealthcarePolicy N/A

Cytokine and CAM Antagonists: T-Lymphocyte Inhibitors Prior Authorization Request Form

Prior authorization request form and clinical criteria checklist for coverage determination of cytokine and CAM antagonists (T-lymphocyte inhibitors) for Washington (Apple Health) members. The form collects member, provider, diagnosis-specific clinical criteria, previous medication trials, and documentation requirements to support approval or continuation of therapy.

Policy Summary

PayerUnitedHealthcare

PolicyCytokine and CAM Antagonists: T-Lymphocyte Inhibitors Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete and fax the prior authorization request form to 866-940-7328 with chart notes and allow at least 24 hours for review.

POLICY UPDATE CHANGES

No material clinical or coverage changes were made in this update.

5Diagnosis-specific checklists included

1Required prior authorization form

4Key disease areas (GVHD, PJIA, PsA, RA)

Coverage Summary

Subject: Cytokine and CAM Antagonists: T-Lymphocyte Inhibitors Prior Authorization. This policy covers the Washington Apple Health prior authorization request form and associated diagnosis-specific clinical criteria checklist used to determine coverage for cytokine and CAM antagonists (T-lymphocyte inhibitors).

Medical-Necessity Criteria

General Prior Authorization / Continuation Criteria

Coverage decision requires completion of form and submission of chart notes; specific diagnosis criteria below must be met as applicable.

ALL of the following

Completed prior authorization request form submitted via fax to 866-940-7328
See form instructions for contact number and review time frame.
Allow at least 24 hours for review
As indicated on the form.
Chart notes are required with this request
Requests lacking required chart notes risk denial.
Request type
- New therapy: indicate as New
  Refer to Section A question regarding New vs Continuation.
- Continuation of therapy: provide start date and documentation demonstrating disease stability or positive clinical response
  See Clinical and Drug Specific Information; chart notes required.
Prescriber requirement
- Prescribed by or in consultation with Dermatologist
  Check all that apply on the form.
- Prescribed by or in consultation with Hematologist
  Check all that apply on the form.
- Prescribed by or in consultation with Oncologist
  Check all that apply on the form.
- Prescribed by or in consultation with Rheumatologist
  Check all that apply on the form.
- Other - specify specialty
  Provide specialty in provider information section.

ref

Non-Preferred Medication / Step Therapy

If request is for non-preferred product:

ALL of the following

Provider must document trial(s) of one or more preferred Cytokine and CAM medications on the Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated; list each medication and duration
Form includes fields to list medication name, duration, and reason for failure.
If preferred medications not tried, provide explanation why preferred product(s) have not been tried
Section E requests explanation why preferred medications would not meet the patient's needs.

Graft Versus Host Disease (GVHD) Criteria

Applicable questions for GVHD diagnosis (questions 7-9):

ALL of the following

If patient received HSCT: indicate if requested drug will be used as additional therapy in combination with corticosteroids for chronic GVHD
Form asks to check if used as additional therapy with corticosteroids.
Document lack of response (e.g., steroid-refractory disease) to first-line therapy options when applicable
Form asks to indicate no response/steroid-refractory disease.
If used for prophylaxis of acute GVHD after HSCT from matched or 1 allele-mismatched unrelated donor, indicate use in combination with a calcineurin inhibitor and methotrexate
Form asks to indicate use with calcineurin inhibitor and methotrexate for prophylaxis.
If applicable, indicate antiviral prophylaxis for EBV reactivation will be provided and will continue for 6 months post-transplantation

Polyarticular Juvenile Idiopathic Arthritis (PJIA) Criteria

Applicable questions for PJIA (questions 10-11):

ALL of the following

Patient has had treatment with at least one non-Cytokine and CAM DMARD (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine) that was ineffective, unless all are contraindicated or not tolerated
Minimum trial of 3 months unless contraindicated or not tolerated.
Minimum trial duration for non-Cytokine and CAM DMARD is 3 months3 months
Document duration of trial on form.
For continuation: documentation demonstrating disease stability or positive clinical response (e.g., improvement in joint swelling, activities of daily living, reduction in disease flares) is required
Continuation requires chart notes showing stability or response.

Psoriatic Arthritis (PsA) Criteria

Applicable questions for PsA (questions 12-15):

ALL of the following

Patient has had treatment with at least one non-Cytokine and CAM DMARD that was ineffective, contraindicated, or not tolerated
Minimum trial of 3 months required unless contraindicated or not tolerated.
Minimum trial duration for non-Cytokine and CAM DMARD is 3 months3 months
Document duration of trial on form.
Disease activity indicators (check if present)
- Active, severe disease indicated by provider assessment
  Question 13 on the form.

Rheumatoid Arthritis (RA) Criteria

Applicable questions for RA (questions 16-18):

ALL of the following

Baseline disease activity assessments submitted (e.g., DAS28-CRP, DAS28-ESR, SDAI, CDAI, RAPID3, PAS II)
Form asks whether baseline assessments have been submitted.
Patient has had treatment with at least one non-Cytokine and CAM DMARD (e.g., methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, cyclosporine, azathioprine) that was ineffective, unless all are contraindicated or not tolerated
Minimum trial of 3 months unless contraindicated or not tolerated.
Minimum trial duration for non-Cytokine and CAM DMARD is 3 months3 months
Document duration of trial on form.

Provider Actions

Prior Authorization

Submit prior authorization request form

Complete and fax the prior authorization request form to 866-940-7328 with chart notes. Allow at least 24 hours for review.

Fax number: 866-940-7328
Allow at least 24 hours for review

Documentation Required

Provide prior therapy and rationale

Document prior medication trials including medication names, strengths, directions, dates of therapy, and reason for discontinuation or intolerance. For non-preferred products, provide an explanation why preferred Apple Health Preferred Drug List (AHPDL) alternatives were ineffective, contraindicated, or not tolerated.

Medication name
Strength
Directions
Dates of therapy
Reason for discontinuation/intolerance
If non-preferred: explain why preferred AHPDL alternatives were ineffective, contraindicated, or not tolerated

Documentation Required

Provide disease-specific objective assessments

Provide disease-specific objective assessments. For rheumatoid arthritis (RA) submit baseline disease activity measures (e.g., DAS28-CRP, DAS28-ESR, SDAI, CDAI, RAPID3, PAS II). For continuation requests, provide documentation demonstrating disease stability or a positive clinical response using these disease activity scores.

Baseline RA scores: DAS28 (CRP or ESR), SDAI, CDAI, RAPID3, PAS II
For continuation: documentation of disease stability or improvement in disease activity scores

Documentation Required

GVHD transplantation prophylaxis documentation

For requests related to GVHD after HSCT, document that the requested drug will be used in combination with a calcineurin inhibitor and methotrexate when indicated, and indicate that antiviral prophylaxis for Epstein-Barr Virus (EBV) reactivation will be provided and continue for 6 months post-transplantation.

Document use in combination with a calcineurin inhibitor and methotrexate for prophylaxis when applicable
Plan for EBV antiviral prophylaxis to continue for 6 months post-transplantation

Denial Risk

Incomplete submission or missing chart notes

Requests lacking required chart notes or missing diagnosis-specific documentation risk denial.

Chart notes are required with this request
Missing diagnosis-specific documentation (e.g., required disease activity scores, prior therapy trials) may result in denial

Prior Authorization

Prescriber signature and specialty required

The prior authorization form must include the prescriber signature, prescriber specialty, and date.

Prescriber signature
Prescriber specialty
Date

Background

Background: The form is intended to capture the clinical information needed to adjudicate prior authorization requests for cytokine and CAM antagonists (T-lymphocyte inhibitors) under Washington Apple Health. Complete the entire form and fax to 866-940-7328; allow at least 24 hours for review.

Types of information collected include: member and provider details (member name, ID, contact, DOB; provider name, NPI, specialty, contact) and the prescriber signature/date; medication and dosing details; specific diagnosis and ICD-10 code; and whether the request is new or a continuation of therapy.

The form requires documentation of prior medication trials (medication name, strength, directions, dates of therapy, reason for discontinuation) and an explanation if preferred products on the Apple Health Preferred Drug List are not appropriate. Chart notes are required with the request.

Diagnosis-specific clinical criteria are collected via checklists for Graft Versus Host Disease (GVHD), Polyarticular Juvenile Idiopathic Arthritis (PJIA), Psoriatic Arthritis (PsA), and Rheumatoid Arthritis (RA), including items such as prior DMARD trials, minimum trial durations (3 months where specified), baseline disease activity measures for RA, and GVHD transplant-specific prophylaxis and antiviral plans.

Definition: AHPDL = Apple Health Preferred Drug List (preferred medications list referenced for step therapy).

OpenPayer

Cytokine and CAM Antagonists: T-Lymphocyte Inhibitors Prior Authorization Request Form

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background

Definitions